2010 05 in the line of duty... Fire Fighter Fatality Investigation and Prevention Program

A summary of a NIOSH fire fighter fatality investigation June, 2010 Captain Dies After Extremely Heavy Physical Exertion at Building Fire from Complications of Surgery– Kansas Executive Summary On December 13, 2009, a 51-year-old male career NIOSH investigators offer the following Captain responded to a fire in a condominium recommendations to address general safety and complex clubhouse. On scene while wearing full health issues. However, it is unlikely that any of turnout gear, he stretched a 2 1/2- and a 3-inch these recommendations could have prevented the hoseline and cut a hole in the building exterior Captain’s death. to access the crawl space. While in rehabilitation (rehab), the Captain experienced persistent Provide annual medical evaluations to all and /. fire fighters consistent with National Fire These symptoms progressed over the next few Protection Association (NFPA) 1582, Standard days resulting in a subsequent diagnosis of mitral on Comprehensive Occupational Medical valve insufficiency/regurgitation. The Captain Program for Fire Departments. underwent surgery to repair his mitral valve on December 29, but suffered an intra-operative Discontinue routine pre-employment/ ( attack) from which preplacement exercise stress tests for he died 4 days later. The death certificate, applicants. completed by the pathologist, listed the cause of death as “massive acute myocardial infarction Ensure fire fighters are cleared for return to duty due to complications from mitral valve annulus by a physician knowledgeable about the physical placement due to severe mitral regurgitation demands of fire fighting, the personal protective aggravated by smoke/chemical inhalation.” The equipment used by fire fighters, and the various autopsy, completed by the pathologist, listed components of NFPA 1582. “massive acute myocardial infarction secondary to kinking and obstruction of the circumflex Phase in a comprehensive wellness and fitness coronary artery resulting from the mitral valve program for fire fighters. annulus placement during mitral valve surgery” as the cause of death. NIOSH investigators agree Perform an annual physical performance with these conclusions. In addition, NIOSH (physical ability) evaluation. investigators believe that the Captain’s acute mitral value insufficiency/regurgitation was due Provide fire fighters with medical clearance to a partial tear/rupture of his . to wear self-contained breathing apparatus as This tear/detachment was probably triggered by part of the Fire Department’s annual medical the heavy physical exertion expended during fire evaluation program. suppression activities on December 13, 2009. A Summary of a NIOSH fire fighter fatality investigation Report #2010-05 Captain Dies After Extremely Heavy Physical Exertion at Building Fire from Complications of Mitral Valve Surgery– Kansas

The National Institute for Occupational Safety and Health (NIOSH) initiated the Fire Fighter Fatality Investigation and Prevention Program to examine of fire fighters in the line of duty so that fire departments, fire fighters, fire service organizations, safety experts and researchers could learn from these incidents. The primary goal of these investigations is for NIOSH to make recommendations to prevent similar occurrences. These NIOSH investigations are intended to reduce or prevent future fire fighter deaths and are completely separate from the rulemaking, enforcement and inspection activities of any other federal or state agency. Under its program, NIOSH investigators interview persons with knowledge of the incident and review available records to develop a description of the conditions and circumstances leading to the deaths in order to provide a context for the agency’s recommendations. The NIOSH summary of these conditions and circumstances in its reports is not intended as a legal statement of facts. This summary, as well as the conclusions and recommendations made by NIOSH, should not be used for the purpose of litigation or the adjudication of any claim.

For further information, visit the program website at www.cdc.gov/niosh/fire or call toll free 1-800-CDC-INFO (1-800-232-4636).

Page 2 A Summary of a NIOSH fire fighter fatality investigation Report #2010-05 Captain Dies After Extremely Heavy Physical Exertion at Building Fire from Complications of Mitral Valve Surgery– Kansas Introduction & Methods Investigative Results On December 13, 2009, a 51-year-old male career Incident. On December 13, 2009, the Captain Captain had persistent palpitations and shortness of arrived for his 24-hour shift at Station 11 (Engine breath in rehab at a structure fire. Subsequent test- 11) at 0700 hours. Two fire fighters were assigned ing revealed mitral valve insufficiency/regurgitation. with the Captain. At 0903 hours, the FD was dis- The Captain underwent surgery to repair the mitral patched to a fire in a condominium clubhouse. The valve insufficiency/regurgitation on December 29, 5,000-square-foot clubhouse was a single story 2009. The Captain died 4 days later. The U.S. Fire wood frame structure with a basement. Engine 9, Administration notified NIOSH of this fatality on Engine 20, Aerial Platform 9, Quint 15, Squad 11, January 4, 2010. NIOSH contacted the affected fire Squad 14, Battalion 9, Safety Officer, and Medi- department (FD) to gather additional information on cal Officer responded on the first alarm. Units January 5, 2010, and on February 4, 2010, to initiate began arriving on scene at 0909 hours and found the investigation. On February 22, 2010, a Safety and heavy smoke conditions. Fire fighters entered the Occupational Health Specialist from the NIOSH Fire structure to find moderate heat conditions, zero Fighter Fatality Investigation Team traveled to Kansas visibility, and a collapsed floor. They began fire to conduct an on-site investigation of the incident. extinguishment without success and backed out of the structure. Aerial 9 ventilated the roof. Weather During the investigation, NIOSH personnel inter- conditions at an airport 2 miles away included fog, viewed the following people: light drizzle, a temperature of 41 degrees Fahren- • Fire Chief heit, 100% relative humidity, and south-southeast • Fire Marshal winds at 14 miles per hour [NOAA 2009]. • Deputy Fire Chief • Safety/Training Chief A second alarm dispatched the following units at • International Association of Fire Fighters (IAFF) 0918 hours: Engine 6, Engine 10, Engine 11 (the • Local President Captain and two fire fighters), Engine 5, Engine • IAFF local secretary 12, Quint 14, Quint 4, Quint 18, Squad 5, Squad • The Captain’s family representative 19, and Squad 36. Engine 11 arrived into staging • Crew members and then was assigned to turn off the natural gas to the building. The crew arrived at the building NIOSH personnel reviewed the following documents: wearing their self-contained breathing apparatus • FD policies and operating guidelines (SCBA) and carrying tools. After the gas was • FD training records turned off, Incident Command declared a defen- • FD annual report for 2009 sive operation, and hoselines were moved to begin • FD incident reports this phase. The Incident Safety Officer noticed the • Witness statements Captain’s “color not being so great” and the Cap- • Hospital emergency department (ED) records tain seemed to be “winded.” • Hospital inpatient records • Death certificate Engine 11 was assigned to the C/D division with • Autopsy report the Captain in command. Using a chain saw, the • Primary care physician records Engine 11 crew cut a hole in the side of the build-

Page 3 A Summary of a NIOSH fire fighter fatality investigation Report #2010-05 Captain Dies After Extremely Heavy Physical Exertion at Building Fire from Complications of Mitral Valve Surgery– Kansas Investigative Results (cont.) ing to access the fire using a 1¾-inch hoseline. arrangements were made for mitral valve surgery Unable to reach the fire, command advised crews on December 29, 2009. The next day, however, to prepare for “master stream” application. Crews the Captain was admitted to the hospital for mild used two preconnected hoselines to protect the congestive secondary to mitral valve C/D side until a 3-inch hoseline with monitor was regurgitation/ insufficiency. A transesophageal set up. After approximately 1 hour on scene, En- echocardiogram (TEE) confirmed the previous gine 11 entered rehab for rest and hydration (1022 echocardiology findings and a cardiac catheter- hours). ization revealed no evidence of with a normal left ventricular ejection In rehab, the Captain’s pulse rate was fast (114 fraction. He was treated with diuretics and dis- beats per minute). Despite removing his turnout charged on December 22 to return on December gear and resting for 5 minutes, his tachycardia 28 for his /replacement surgery remained. After 30-45 minutes in rehab, the Cap- on December 29, 2009. tain’s pulse returned to the upper threshold limits and he was released (1052 hours). The fire was On December 29, 2009, an intraoperative TEE declared under control at 1100 hours, and crews showed an enlarged left and mild concen- began to gather equipment. The Captain assisted tric LVH with normal cardiac output. Anterior and in rolling hoselines and moving heavy equipment posterior leaflets of the mitral valve were thick- between engines. The crew returned to the fire sta- ened and myxomatous, resulting in severe mitral tion at 1341 hours. valve prolapse. Portions of the posterior leaflet and corresponding chordae were either detached Although the Captain’s symptoms of palpitations or seriously disrupted, resulting in the mitral valve and shortness of breath transiently improved after insufficiency/regurgitation. The intraoperative the fire, his symptoms returned and persisted the TEE was followed by the surgical repair of the remainder of his shift and further deteriorated mitral valve. An intraoperative TEE following the over the next 5 days. On December 18, 2009, repair showed a markedly hypokinetic left and the Captain sought medical evaluation from his right . The inferior and posterior portions primary care physician, who found a loud heart of the left ventricle were severely hypokinetic, if murmur (holosystolic 3/6 at the apex) and ordered not akinetic. Four days after the surgery the Cap- an electrocardiogram (EKG), which revealed sinus tain died from complications of the surgery. tachycardia (111 beats per minute) with left ven- tricular hypertrophy (LVH). He was referred to Medical Findings. The death certificate, com- a cardiologist whose echocardiogram diagnosed pleted by the pathologist, listed “massive acute mitral valve prolapse with severe mitral valve myocardial infarction due to complications from regurgitation (posterior leaflet). His echocardio- mitral valve annulus placement due to severe mi- gram also showed a normal left ventricular ejec- tral regurgitation aggravated by smoke/chemical tion fraction (55%–60%) and no LVH; both find- inhalation.” Further, a medical opinion provided ings suggest a recently acquired problem. He was by the Medical Intensive Cardiac Unit Medical prescribed medication to control his heart rate, and Director stated “The sudden and persistent chang-

Page 4 A Summary of a NIOSH fire fighter fatality investigation Report #2010-05 Captain Dies After Extremely Heavy Physical Exertion at Building Fire from Complications of Mitral Valve Surgery– Kansas Investigative Results (cont.) Description of the Fire Department es in the Captain’s physical condition after fight- At the time of the NIOSH investigation, the ca- ing the structure fire on December 13th are con- reer FD consisted of 22 fire stations with 440 sistent with acute rupture of chordate tendineae to uniformed personnel that served a population of the posterior leaflet on the mitral valve caused by 368,000 residents in a geographic area of 168 a period of extreme physical exertion while fight- square miles. ing the structure fire.” The autopsy, completed by the pathologist, listed “massive acute myocardial In 2009, the FD responded to 42,876 calls: 1,645 infarction [heart attack] secondary to kinking fires, 1,117 hazardous condition calls, 63 over- and obstruction of the circumflex coronary artery pressure calls, 1,632 system alarms, 4,315 good resulting from the mitral valve annulus placement intent calls, 2,663 public service calls, 31 weather- during mitral valve surgery” as the cause of death. related calls, 58 other service calls, and 31,352 Specific findings from the autopsy are listed in medical calls. Appendix A. Employment and Training. The FD requires all The Captain’s last medical evaluation was con- fire fighter candidates to pass a general aptitude ducted in 2008 as part of a one-time grant. This test and a physical ability test. The FD ranks ap- evaluation was significant for no history of , plicants based on their scores. The FD then inter- a normal pulse, and no . As part of views the top 30% and gives credit for relevant this evaluation the Captain had a treadmill ex- college classes, experience, and technical train- ercise stress test (EST) at which time the record ing. A new list is formed, and depending on the mentions a history of “heart beat skipping a beat number of fire fighters to be hired, the FD offers at about 120 bpm [beats per minute].” Results of positions to the top candidates pending results of the EST show the Captain exercised for 10 min- a physical examination and drug screen. License utes, 10 seconds of the Bruce protocol, achieving and background checks are conducted, as well 12.1 metabolic equivalents (METS). The test was as verification of Emergency Medical Techni- stopped when the Captain reached 100% of his cian (EMT) training. The recruit class is formed, target heart rate. He experienced no angina, had and recruits attend a 10-week FD academy. New a normal response to the exercise, recruits are then assigned to a fire station and, had no , and had no ischemic changes. after one year of probation, are given the basic Prior to the incident described in this report, the Fire Fighter-I skills test. Further training to Fire Captain never reported episodes of shortness of Fighter-II is conducted in the fire station until the breath on exertion, angina, palpations, or any Fire Fighter-II examination has been passed. The other cardiac problems to his family or the FD. Captain was certified as a Fire Fighter II, Fire Of- ficer I, EMT, in HazMat operations, and Technical Rescue. He had 28 years of fire fighting experi- ence.

Page 5 A Summary of a NIOSH fire fighter fatality investigation Report #2010-05 Captain Dies After Extremely Heavy Physical Exertion at Building Fire from Complications of Mitral Valve Surgery– Kansas Description of the Fire Department (cont.) Preplacement Medical Evaluation. A preplace- ment (strength and aerobic) is available in all fire ment medical examination is required by this FD stations. A return-to-duty medical clearance is for all applicants. The contents of the examination required from the City-contracted physician for are as follows: duty-related injuries. Fire fighters who miss more • Complete medical and occupational history than five shifts due to illness must have a release • Height, weight, and vital signs from their primary care physician before they may •Physical examination return to work. There is no medical component to • Blood tests: complete blood count, lipid panel, and the SCBA program, but a fit test is performed an- liver profile nually. Health maintenance programs are available • Urine tests: urinalysis and urine drug screen through the City employee assistance program. • Chest x-ray (posteroanterior and lateral views) with interpretation and report • 12-lead resting EKG with interpretation and report • Treadmill EST • Audiometry • Vision test • Functional capacity evaluation

These evaluations are performed by a physician under contract to the City. Once this evaluation is complete, the physician makes a determination regarding medical clearance for fire fighting duties and forwards this decision to the FD.

Periodic Medical Evaluations. Required medical evaluations are offered every other year to hazard- ous materials (hazmat) technician-level responders assigned to the Hazmat team. A City-contracted physician performs the medical evaluations and forwards the clearance-for-duty decision to the FD, which makes the final determination. The FD offered a medical evaluation for all fire fighters in 2008 paid for by a Federal grant, but participation was voluntary. As mentioned earlier, the Captain had the evaluation in 2008.

Health and Wellness Programs. No physical agil- ity test is required for members, but the FD has a voluntary fitness program where exercise equip-

Page 6 A Summary of a NIOSH fire fighter fatality investigation Report #2010-05 Captain Dies After Extremely Heavy Physical Exertion at Building Fire from Complications of Mitral Valve Surgery– Kansas Discussion Mitral Valve Prolapse. Mitral valve prolapse oc- Like the clinical presentation, the clinical course curs when one or both of the mitral valve leaflets and prognosis are variable. Patients can remain prolapse into the left atrium during (con- asymptomatic, but some cases progress over de- traction of the heart muscle). It is the most com- cades to severe regurgitation, putting the patient at mon disorder, affecting about 2%–4% risk for (infection of the heart valve), of the population. Both sexes and all ages can strokes, and arrhythmias. Arrhythmias associated be affected [O’Gara and Braunwald 2008]. The with mitral valve prolapse can cause palpitations, prolapse can be due to problems with the valve , and . The Captain’s leaflets or other parts of the mitral valve apparatus symptoms of palpitation were probably related (e.g., annulus; chordae tendineae; papillary mus- to an associated with his mitral value cles; and the supporting walls of the left ventricle, prolapse. His more recent symptoms of fatigue left atrium, and the aorta) [Bonow et al. 2006; and shortness of breath were probably related to Gabbay and Yosefy 2010]. Problems with the the acute (sudden onset) tear/rupture of the chor- valve leaflets are classified as primary mitral valve dae tendineae causing mitral valve insufficiency/ prolapse (Appendix B). regurgitation.

The basic microscopic feature of primary mitral Mitral Valve Insufficiency/Regurgitation. Chor- valve prolapse is marked thickening and redun- dae tendineae rupture of any mitral valve leaflet is dancy of the middle layer of the valve leaflet the most common cause of acute mitral regurgita- (myxomatous proliferation of the spongiosa tion requiring prompt surgery. Chordae arising ) [Bonow et al. 2006]. During from a myxomatous mitral valve are likely to tear surgery, the Captain’s mitral valve was noted to or rupture at a lower tensile stress or at a lower be myxomatous. Clinical presentations of mitral absolute load [Barber et al. 2001]. In addition, ex- valve prolapse range from asymptomatic heart treme physical exertion can trigger or precipitate murmurs to severe mitral valve regurgitation with an acute chordate rupture in a myxomatous valve, symptoms of fatigue, shortness of breath on ex- resulting in acute mitral regurgitation [Brizzio and ertion, and reduced exercise tolerance [O’Gara Zapolanski 2008]. The Captain’s mitral insuffi- and Braunwald 2008]. The diagnosis is made by ciency/regurgitation was probably due to an acute , which measures the abrupt pos- rupture/tear of the chordae tendineae of his mitral terior movement of one or both of the mitral valve valve’s posterior leaflet. The chordae tear/rupture leaflets [Malkowski and Pearson 2000]. The EKG was probably due to a combination of his under- is usually normal in asymptomatic patients, but lying myxomatous valve and the heavy physical more severe cases can show signs of LVH. Prior to exertion expended during fire suppression activi- this incident, the Captain did not have any symp- ties on December 13, 2009. toms associated with a mitral valve prolapse, nor did he present with LVH on his echocardiogram.

Page 7 A Summary of a NIOSH fire fighter fatality investigation Report #2010-05 Captain Dies After Extremely Heavy Physical Exertion at Building Fire from Complications of Mitral Valve Surgery– Kansas Discussion (cont.) Recommendations Occupational Medical Standards for Structural NIOSH investigators offer the following Fire Fighters. To reduce the risk of sudden car- recommendations to address general safety and diac arrest or other incapacitating medical condi- health issues. However, it is unlikely that any of tions among fire fighters, the NFPA developed these recommendations could have prevented the NFPA 1582, Standard on Comprehensive Occu- Captain’s death. pational Medical Program for Fire Departments [NFPA 2007a]. This voluntary industry standard Recommendation #1: Provide annual medical provides medical requirements for candidates and evaluations to all fire fighters consistent with current fire fighters. The Captain’s last FD medical National Fire Protection Association (NFPA) 1582, evaluation was in 2008. In this case, the Captain’s Standard on Comprehensive Occupational Medical last medical evaluation indicated no mitral valve Program for Fire Departments. prolapse. If a mitral valve prolapsed had been de- tected, as part of an earlier diagnosis, the diagnosis Guidance regarding the content and frequency of would probably not have precluded the Captain’s these evaluations can be found in NFPA 1582 and in work as a fire fighter or prevented his death. the International Association of Fire Fighters (IAFF)/ International Association of Fire Chiefs (IAFC) Fire Service Joint Labor Management Wellness/Fitness Initiative [NFPA 2007a; IAFF, IAFC 2008]. These guidelines help to determine fire fighters’ medical ability to perform duties without presenting a significant risk to the safety and health of themselves or others. However, the FD is not legally required to follow this standard or this initiative. This recommendation is unlikely to have prevented his work as a fire fighter or prevented his death from complications of his mitral valve surgery.

The FD requires hazmat medical evaluations for hazmat team members. As part of this evaluation, the FD is conducting routine chest x-rays and blood testing for heavy metals and aromatic hydrocarbons. While these tests may be indicated for hazmat fire fighters exposed to specific chemicals, they should not be conducted routinely and represent an unnecessary expense for the FD. The FD should consider re-evaluating the scope of its hazmat medical evaluation [DHHS 1985].

Page 8 A Summary of a NIOSH fire fighter fatality investigation Report #2010-05 Captain Dies After Extremely Heavy Physical Exertion at Building Fire from Complications of Mitral Valve Surgery– Kansas Recommendations (cont.) Recommendation #2: Discontinue routine pre- Recommendation #4: Phase in a comprehensive employment/preplacement exercise stress test. wellness and fitness program for fire fighters.

Currently the FD is conducting an exercise stress Guidance for fire department wellness/fitness test on all applicants during their preplacement programs is found in NFPA 1583, Standard on medical evaluation, regardless of the number or Health-Related Fitness Programs for Fire Fighters, severity of their coronary artery disease (CAD) the International Association of Fire Fighters/ risk factors. This testing represents an unnecessary International Association of Fire Chiefs (IAFF/ medical expense for the FD. The American Heart IAFC) Fire Service Joint Labor Management Association/American College of and Wellness/Fitness Initiative, and in the Firefighter NFPA 1582 recommend an exercise stress test only Fitness: A Health and Wellness Guide [USFA for people/FFs at increased risk for CAD. NFPA 2004; IAFF, IAFC 2008; NFPA 2008; Schneider defines increased risk as two or more CAD risk 2010]. Worksite health promotion programs have factors in male FFs over the age of 45 and female been shown to be cost effective by increasing FFs over the age of 55 [Gibbons et al. 2002; NFPA productivity, reducing absenteeism, and reducing 2007a]. the number of work-related injuries and lost work days [Stein et al. 2000; Aldana 2001]. Fire service Recommendation #3: Ensure fire fighters health promotion programs have been shown to are cleared for return to duty by a physician reduce CAD risk factors and improve fitness levels, knowledgeable about the physical demands of fire with mandatory programs showing the most benefit fighting, the personal protective equipment used by [Dempsey et al. 2002; Womack et al. 2005; Blevins fire fighters, and the various components of NFPA et al. 2006]. A study conducted by the Oregon Health 1582. and Science University reported a savings of over $1 million for each of four large fire departments Currently, a State Workers’ Compensation physician implementing the IAFF/IAFC wellness/fitness reviews and approves return to duty clearances for program compared to four large fire departments fire fighters injured on duty. For long-term illnesses, not implementing a program. These savings were the fire fighter’s personal physician approves return primarily due to a reduction of occupational injury/ to duty. These physicians may not be aware of the illness claims with additional savings expected physiological and psychological demands on fire from reduced future nonoccupational healthcare fighters, the environmental conditions under which costs [Kuehl 2007]. NIOSH recommends a formal, they must perform, and the personal protective structured wellness/fitness program to ensure all equipment fire fighters must wear during various members receive the benefits of a health promotion types of emergency operations. Therefore, we program. recommend the FD have an officially designated physician who is responsible for guiding, directing, Recommendation #5: Perform an annual physical and advising the members with regard to their performance (physical ability) evaluation. health, fitness, and suitability for duty [NFPA 2007a; NFPA 2007b; IAFF, IAFC 2008].

Page 9 A Summary of a NIOSH fire fighter fatality investigation Report #2010-05 Captain Dies After Extremely Heavy Physical Exertion at Building Fire from Complications of Mitral Valve Surgery– Kansas Recommendations (cont.) References NFPA 1500 recommends fire department members Aldana SG [2001]. Financial impact of health pro- who engage in emergency operations be annually motion programs: a comprehensive review of the evaluated and certified by the FD as having met literature. Am J Health Promot 15(5):296–320. the physical performance requirements identified in paragraph 10.2.3 of the standard [NFPA 2007b]. Barber JE, Ratliff NB, Cosgrove DM 3rd, Griffin This is recommended to ensure fire fighters are BO, Vesely I [2001]. Myxomatous mitral valve physically capable of performing the essential job chordae. I: mechanical properties. J Heart Valve tasks of structural fire fighting. The physical ability Dis 10(3):320–324. test could be performed as part of the FD’s annual training program. Blevins JS, Bounds R, Armstrong E, Coast JR [2006]. Health and fitness programming for fire Recommendation #6: Provide fire fighters fighters: does it produce results? Med Sci Sports with medical clearance to wear self-contained Exerc 38(5):S454. breathing apparatus as part of the Fire Department’s annual medical evaluation Bonow RO, Carabello BA, Chatterjee K, de Leon program. AC Jr., Faxon DP, Freed MD, Gaasch WH, Whitney Lytle B, Nishimura RA, O’Gara PT, The Occupational Safety and Health Administration O’Rourke RA, Otto CM, Shah PM [2006]. (OSHA) Revised Respiratory Protection Standard ACC/AHA 2006 guidelines for the management of requires employers to provide medical evaluations patients with : and clearance for employees using respiratory executive summary. A report of the American Col- protection prior to being fit tested [29 CFR1 lege of Cardiology/American Heart 1910.134]. Employees must receive annual medical Association Task Force on Practice Guidelines evaluations to determine fitness for duty to wear (Writing Committee to Revise the 1998 personal protective equipment (respirators), unless Guidelines for the Management of Patients With the physician believes a semiannual evaluation is Valvular Heart Disease). J Am Coll Card appropriate 29 CFR 1910.120]. These clearance 48(3):e1–e148. evaluations are required for private industry employees and public employees in States Brizzio ME, Zapolanski A [2008]. Acute mitral operating OSHA-approved State plans [OSHA regurgitation requiring urgent surgery because of 2010]. The clearances are completed as part of chordate ruptures after extreme physical exercise: the fire department medical evaluation program. a case report. Heart Surgery Forum Kansas does not operate an OSHA-approved 11(4):E255–E256. State plan for the public sector; therefore, public sector employers (including volunteer/paid fire CFR. Code of Federal Regulations. Washington, departments) are not required to comply with DC: U.S. Government Printing Office, Office of OSHA standards. However, NIOSH investigators the Federal Register. recommend following this standard to ensure an increased level of medical fitness and safety.

Page 10 A Summary of a NIOSH fire fighter fatality investigation Report #2010-05 Captain Dies After Extremely Heavy Physical Exertion at Building Fire from Complications of Mitral Valve Surgery– Kansas References (cont.) DHHS [1985]. Occupational safety and health IAFF, IAFC [2008]. The fire service joint labor guidance manual for hazardous waste site management wellness/fitness initiative. 3rd ed. activities. U.S. Department of Health and Human Washington, DC: International Association of Fire Services. Washington, DC: U.S. Government Fighters, International Association of Fire Chiefs. Printing Office. DHHS Publication 85-115. Kuehl K [2007]. Economic impact of the wellness Dempsey WL, Stevens SR, Snell CR [2002]. fitness initiative. Presentation at the 2007 John P. Changes in physical performance and medical Redmond Symposium in Chicago, IL on October measures following a mandatory firefighter well- 23, 2007. ness program. Med Sci Sports Exerc 34(5):S258. Malkowski MJ, Pearson AC [2000]. The echocar- Gabbay U, Yosefy C [in press]. The underlying diographic assessment of the floppy mitral valve: causes of chordae tendinae rupture: a systematic an integrated approach. In: Boudoulas J, Wooley review. Int J Card. [http://www.science- CF (eds). Mitral valve: floppy mitral valve, mitral direct.com/science?_ob=ArticleURL&_ valve prolapse, mitral valvular regurgitation. 2nd udi=B6T16-4YJCTHG-1&_user=925725&_ ed. Armonk, NY: Futura, pp. 231–252. coverDate=08%2F20%2F2010&_ alid=1449042464&_rdoc=1&_fmt=high&_ NFPA [2007a]. Standard on comprehensive oc- orig=search&_origin=search&_zone=rslt_ cupational medical program for fire departments. list_item&_cdi=4882&_sort=r&_ Quincy, MA: National Fire Protection Association. st=13&_docanchor=&view=c&_ct=1&_ NFPA 1582. acct=C000046148&_version=1&_ urlVersion=0&_userid=925725&md5=9493986b7 NFPA [2007b]. Standard on fire department occu- a74eebd58eb3feaac62a8b0&searchtype=a]. pational safety and health program. Quincy, MA: Date accessed: May 2010. National Fire Protection Association. NFPA 1500.

Gibbons RJ, Balady GJ, Bricker JT, Chaitman NFPA [2008]. Standard on health-related fitness BR, Fletcher GF, Froelicher VF, Mark DB, Mc- programs for fire fighters. Quincy, MA: National Callister BD, Mooss AN, O’Reilly MG, Winters Fire Protection Association. NFPA 1583. WL Jr., Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Russell NOAA [2009]. Quality controlled local climato- RO, Smith SC Jr. [2002]. ACC/AHA 2002 guide- logical data. McConnell AFB Airport. National line update for exercise testing: a report of the Oceanic and Atmospheric Administration. [http:// American College of Cardiology/American Heart cdo.ncdc.noaa.gov/qclcd/QCLCD]. Date accessed: Association Task Force on Practice Guidelines. May 2010. Circulation 106(14):1883–1892. OSHA [2010]. State Occupational Safety and Health Plans. [http://www.osha.gov/fso/osp/index. html]. Date accessed: May 2010.

Page 11 A Summary of a NIOSH fire fighter fatality investigation Report #2010-05 Captain Dies After Extremely Heavy Physical Exertion at Building Fire from Complications of Mitral Valve Surgery– Kansas References (cont.) Investigator Information O’Gara P, Braunwald E [2008]. Valvular heart disease. In: Fauci AS, Braunwald E, Kasper DL, This incident was investigated by the NIOSH Hauser SL, Longo DL, Jameson JL, Loscalzo J, Fire Fighter Fatality Investigation and Pre- eds. Harrison’s principles of internal medicine. vention Program, 17th ed. New York: McGraw-Hill, pp. 1465–1480. Component located in Cincinnati, Ohio. Mr. Tommy Baldwin (MS) led the investigation Schneider EL [2010]. Firefighter fitness: a health and co-authored the report. Mr. Baldwin is a and wellness guide. New York, NY: Nova Science Safety and Occupational Health Specialist, Publishers. a National Association of Fire Investigators (NAFI) Certified Fire and Explosion Investi- Stein AD, Shakour SK, Zuidema RA [2000]. gator, an International Fire Service Accredita- Financial incentives, participation in employer tion Congress (IFSAC) Certified Fire Officer sponsored health promotion, and changes in I, and a former Fire Chief and Emergency employee health and productivity: HealthPlus Medical Technician. Dr. Thomas Hales (MD, health quotient program. J Occup Environ Med MPH) provided medical consultation and 42(12):1148–1155. co-authored the report. Dr. Hales is a member of the NFPA Technical Committee on Oc- USFA [2004]. Health and wellness guide. Em- cupational Safety and Heath, and Vice-Chair mitsburg, MD: Federal Emergency Management of the Public Safety Medicine Section of the Agency; United States Fire Administration. Publi- American College of Occupational and Envi- cation No. FA-267. ronmental Medicine (ACOEM).

Womack JW, Humbarger CD, Green JS, Crouse SF [2005]. Coronary artery disease risk factors in firefighters: effectiveness of a one-year voluntary health and wellness program. Med Sci Sports Ex- erc 37(5):S385.

Page 12 A Summary of a NIOSH fire fighter fatality investigation Report #2010-05 Captain Dies After Extremely Heavy Physical Exertion at Building Fire from Complications of Mitral Valve Surgery– Kansas Appendix A Autopsy Findings

• Cardiac o Acute transmural myocardial infarction (MI) involving approximately 50% of the left ventricle and 50% of the right ventricle beginning at the apex and extending to the valve rings with a gross age of approximately 4 days (December 31, 2009) o Circumflex coronary artery has a severe 90-degree kink with obstruction of the lumen as it abuts and touches the prosthetic annulus placed in the mitral valve ring o Left circumflex coronary artery discolored distal to the kink compatible with intraluminal thrombosis o (enlarged heart) (heart weighed 590 grams [g]; predicted normal weight is 358 g [ranges between 271 g and 473 g as a function of sex, age, and body weight]) [Silver and Silver 2001] o Mild (25%) focal narrowing of the left anterior descending coronary artery o No focal narrowing of the right coronary artery o No atherosclerosis in circumflex coronary artery o Mitral valve repair with one broken suture in the lateral portion of the annulus o Normal aortic, tricuspid, and pulmonic valves • No evidence of a pulmonary embolus (blood clot in the lung arteries) • Acute fibrinous • Pulmonary edema and intra-alveolar hemorrhage • Extensive centrilobular necrosis and congestion of the liver • Extensive acute tubular necrosis of the kidneys • Renal fibrin thrombi consistent with disseminated intravascular coagulation • Acute interstitial pancreatitis • Congestive splenomegaly • Steatosis of the liver

Microscopic examination of the left and right ventricles revealed extensive myocyte necrosis with neu- trophilic inflammation with hemorrhage and degeneration of the neutrophils consistent with an infarct of 4 days of age.

REFERENCES

Silver MM, Silver MD [2001]. Examination of the heart and of cardiovascular specimens in surgical pathology. In: Silver MD, Gotlieb AI, Schoen FJ, eds. Cardiovascular pathology. 3rd ed. Philadelphia, PA: Churchill Livingstone, pp. 8–9.

Page 13 A Summary of a NIOSH fire fighter fatality investigation Report #2010-05 Captain Dies After Extremely Heavy Physical Exertion at Building Fire from Complications of Mitral Valve Surgery– Kansas Appendix B Classification of Mitral Valve Prolapse [Bonow et al. 1998]

Primary Mitral Valve Prolapse Familial Nonfamilial Marfan’s syndrome Other connective tissue diseases

Secondary MVP Coronary artery disease Rheumatic heart disease Reduced LV dimensions Hypertrophic Pulmonary hypertension Dehydration Straight-back syndrome/ “Flail” mitral valve leaflet(s)

Normal variant Inaccurate “Echocardiographic heart disease”

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